Provider Demographics
NPI:1194965483
Name:FAJARDO, IRENA C (LICSW)
Entity type:Individual
Prefix:MS
First Name:IRENA
Middle Name:C
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2420
Mailing Address - Country:US
Mailing Address - Phone:206-257-0608
Mailing Address - Fax:
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX 359760
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-744-5604
Practice Address - Fax:206-744-4505
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000096861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical